Bruce S. Abe Periodontics -
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Bruce S. Abe Periodontics
501 Washington Street, Ste. 740, San Diego, CA 92103
619-393-7511
1. Patient Information
Date Referred
Referring Doctor
Patient Name
Date of Birth
Email
Phone Number
Imaging Provided
Upload & Attach FMX
CT Scan taken sent by cloud/USB/Disc
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2. Evaluation For
Gum Disease
Indicate Area
Gum Recession
Indicate Area
Tooth Removal
Indicate Area
Dental Implants
Indicate Area
Oral Pathology
Indicate Area
Crown Lengthening
Indicate Area
Other
Indicate Area
If you need help with this form or want to see if your patient can be seen the same day, please call our office.
619-393-7511
3. Additional Information
Patient Name Validation
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